HCMII

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We are always looking for dynamic, experienced people to join our growing team.
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CGFNS

American Nursing Association

Canadian Nursing Association

American Hospital Association

NCLEX

National League of Nursing

The application procedure for healthcare position has various steps to follow. The filling out of application is just the first step. You can instantly access the application either by downloading and print or a you can fill on line.

If you are inquiring outside of North America, it would always save your time mailing your resumes to our International Headquarters in Canada and one copy to the respective office in the country you are located.

To download and complete an application, you need to install an Adobe Acrobat Reader. The Acrobat Readers is free and can be downloaded from Adobe.com website.

Download the application
Or fill on-line application.

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Category
Personal Information
Last Name
First Name	Middle Name
Social Security #
Home Phone
Work Phone
Address
Apt/Suite
City
State
Zip Code
Emergency Contact
Relationship
Address
Phone
Salary Desired
Date you can start
Present Citizenship
Resident of
If not, Visa Status

Education

If you were educated or employed under a different name (e.g. maiden name, citizenship name change, etc.) please indicate the purposes of verifying credentials and references.

High School

Address

From (mo/yr) to (mo/yr)

Major Field/Degree

Did you graduate?

College

Address

From (mo/yr) to (mo/yr)

Major Field/Degree

Did you graduate?

Other

Address

From (mo/yr) to (mo/yr)

Major Field/Degree

Did you graduate?

Graduate School

Address

From (mo/yr) to (mo/yr)

Major Field/Degree

Did you graduate?

Employment History
List most recent or current first.
Employer Name
Job Title
From (mo/yr) to (mo/yr)
Address
Supervisor's Name
Phone
May we check reference?
Job Type
Reason For Leaving
Duties Performed
Employer Name
Job Title
From (mo/yr) to (mo/yr)
Address
Supervisor's Name
Phone
May we check reference?
Job Type
Reason For Leaving
Duties Performed
Employer Name
Job Title
From (mo/yr) to (mo/yr)
Address
Supervisor's Name
Phone
May we check reference?
Job Type
Reason For Leaving
Duties Performed

Skills & Qualifications
Typing Speed	(WPM)
Others	(Office, Mechanical etc.)
Language Fluency	(Read & Speak)
Did you graduate?
Professional, Trade or Technical Registration or Licence
Name
Type
Number
Date Issued
State/County Issued
Expiry Date
Memberships in scientific/professional organizations you consider relevant to the job you are seeking:

Additional Information
From
To
Final Rank
DO you have any physical, mental or medical impairment that could interfere with your ability to perform the job that you are seeking? If Yes, please explain.

Have you ever been convicted of any crime (felony or misdemeanor)?

If YES, state each crime for which convicted, the date of conviction and the court where convicted. PLEASE NOTE: A Police clearance may be needed to obtain a visa for specific countries.

Would you be willing to accept an unaccompanied (i.e. no spouse or children) status position?

Comments :

How did you hear about us?
Journal
Referral
Web Site
Other
This space may be used to expand upon any previous entry or to provide detailed information you consider pertinent to your prospective employment.

Medical Questionnaire
Please select the appropriate column if you have or have had the following complaints or symptoms or if you have been advised to seek treatment for :
1	Heart Attack
2	Kidney Stones
3	Stomach or Duodenal Ulcer
4	Muscular weakness-paralysis
5	Need to wear orthopedic braces/appliances
6	Backache
7	Asthma
8	Hernia
9	Diabetes Mellitus
10	Tumor or Cancer
11	Emotional Stress
12	Herniated Disc
13	Multiple Sclerosis
14	Arthritis
15	Advised to have surgery
16	Difficulty seeing
17	Difficulty hearing
18	Seizures (convulsion)
19	Stroke
20	High blood pressure
21	Frequent Headaches
22	Ever tested + for Hepatitis B?
23	Ever tested + for Hepatitis C?

Explanation of YES Answers Above
#	Explanation

What medicines do you take
Name	Frequency & Reason






Average Weekly Tobacco Consumption
Average Weekly Alcohol Consumption

Medical Care/Hospitalization in past 10 years
Date	Reason	Surgery Performed	Result




I affirm the information given is true and correct. I understand that false or misleading information may result in my dismissal. Further, by completion and submission of this form, I authorize you to secure all information in connection with my application for employment. This may include matters of opinion, character, conduct, reputation and ability. I authorize and request each company, organization and/or individual named herein to furnish the requested information. I understand a physical examination is required, and should I fail to pass or if for any reason it is determined that I am not qualified for employment, I may not be employed and you shall not be liable for loss or damage as a result.

Reference Authorization

I understand that considerable effort on the part of HealthCare Management International Inc (or its subsidiaries) may be expended in considering me for a position. Such efforts may include a personal interview and reference checks exploring my past performance on the job as well as character references. I authorize HCM International Inc. to contact my past employers or educational institutions. I further authorized all past employers / educational institutions and all offices of record to release any information that will facilitate a full evaluation of my qualifications for possible employment.

Please list the names of THREE (3) work related supervisory level references:
We require current letters of reference from these present and past supervisors who have worked with you within the past five (5) years

Name
Professional Relationship
Phone
Hospital/Institution
Fax
Best time to call
Address
Ref. Letter Attached?	If No, when can we expect it
If yes, upload document
Name
Professional Relationship
Phone
Hospital/Institution
Fax
Best time to call
Address
Ref. Letter Attached?	If No, when can we expect it
If yes, upload document
Name
Professional Relationship
Phone
Hospital/Institution
Fax
Best time to call
Address
Ref. Letter Attached?	If No, when can we expect it
If yes, upload document

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